Provider Demographics
NPI:1356443436
Name:FELICIANO, REBECCA J (PT MS)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:J
Last Name:FELICIANO
Suffix:
Gender:F
Credentials:PT MS
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:JUDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT MS
Mailing Address - Street 1:101 PHOENIX AVENUE
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4471
Mailing Address - Country:US
Mailing Address - Phone:860-741-2541
Mailing Address - Fax:860-745-5264
Practice Address - Street 1:101 PHOENIX AVENUE
Practice Address - Street 2:SUITE 2D
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4471
Practice Address - Country:US
Practice Address - Phone:860-741-2541
Practice Address - Fax:860-745-5264
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006990225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080006990CT03OtherANTHEM BCBS CT
CT6500001115Medicare PIN